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Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 97-99

Gender dysphoria in an Omani female

1 Clinical Psychologist, Child Development Clinic, SQUH, Muscat, Oman
2 Behavioral Medicine, SQUH, Muscat, Oman

Date of Web Publication11-Apr-2016

Correspondence Address:
Hamed Al Sinawi
Department of Behavioral Medicine, Sultan Qaboos University Hospital, P.O. Box 35, Al Khoudh - 123, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0738.179970

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A case of a girl who presented with symptoms of gender dysphoria is described here. She received cognitive behavioral therapy that helped her explore her thoughts and address any distorted cognition. She was able to live as a female and changed her mind about undergoing sex change surgery. This article explores the concept of gender dysphoria and the role of psychological interventions in its management.

Keywords: Case report, gender dysphoria, Oman, psychotherapy

How to cite this article:
Ali A, Al Sinawi H, Al Alawi M. Gender dysphoria in an Omani female. Int J Nutr Pharmacol Neurol Dis 2016;6:97-9

How to cite this URL:
Ali A, Al Sinawi H, Al Alawi M. Gender dysphoria in an Omani female. Int J Nutr Pharmacol Neurol Dis [serial online] 2016 [cited 2023 Jan 29];6:97-9. Available from:

   Introduction Top

Gender identity disorder in children or adolescents is manifested by a strong and persistent cross-gender identification, with a desire to be, or the insistence that one is, the other sex. [1] The refusal of the assigned gender causes significant distress. In girls, the signs may be the refusal to wear female clothing, makeup, or jewelry and preferring rough-and-tumble play. [2] Most of the epidemiological studies on the prevalence of gender dysphoria came from the West. The onset of cross-gender behavior is often observed between the ages of 2 years and 4 years and, it is around this age when children are seen in specialized clinics. [3] Follow-up studies suggest that the symptoms of gender dysphoria are not always persistent, and affected children eventually exhibit gender appropriate behavior. In males the symptoms persist in 2.2-30% of the cases, whereas in females, symptoms persist in 12-50% of the cases. For natal adult males (who were called males since birth), persistence ranges from 0.005% to 0.014%, and for natal females, it ranges from 0.002% to 0.003%. It is noteworthy that those statistics might be an underestimate because not all people with gender dysphoria seek medical or surgical treatment for gender reassignment. Research studies also suggest gender differences in rate of referral to a specialized clinic that is inconsistent across the age groups. In children, sex ratios of natal boys to girls range from 2:1 to 4.5:1 whereas In adolescents, the sex ratio is close to parity; in adults, the sex ratio favors natal males, with ratios ranging from 1:1 to 6.1:1. [1] Seeking gender assignment surgery is noted to vary among difference cultures with the rate being higher in the western countries compared to the eastern countries such as Japan where studies suggest. Approximately, 1 in 11,000 men (0.00009%) [4] and 1 in 30,000 women (0.003%) seek treatment for gender dysphoria at specialized clinics. [5] In this paper, the case of a 17-year-old girl with gender identity disorder is described, to the authors' knowledge, this is the first case from Oman.

   Case Report Top

The subject (Ms. B), a 17-year-old girl, attended our behavioral medicine department with her mother. She is the third child out of the four children of healthy parents of Omani origin. Ms. B had no personal or family history of mental illness. She described feeling sad and upset, and thinking of ending her life because of feeling trapped in the wrong body since the age of 13. She felt she was a boy and gave herself a boy's name that her mother and close friends started using when addressing her. She described falling in love with another girl. At home, she dressed in boy's clothes and had a boy-like haircut. She refused to wear dresses or makeup. Her mother accompanied her to hospitals before the sex change surgery. Ms. B was born at full term after an uneventful pregnancy and had normal developmental milestones. She attended school at the age of 5 and had good academic performance and was liked by her teachers and peers. No behavioral disorders were reported. She attained menarche at the age of 13 and had regular menstrual periods. Mental state examination showed the patient as a well-dressed female, cooperative and with good rapport. Her speech was coherent and her mood was euthymic. She described wanting to "have the operations to free herself and live a happy life as a boy". She had no abnormal thought content or abnormal perception and had a normal cognitive assessment. Physical examination showed a well-built female with stable vital signs. Her general and neurological examination were normal. She had normal secondary sexual characteristics. All blood tests including hormonal assays were normal. Ms. B's symptoms fulfill the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM5) criteria of gender dysphoria. She started undergoing a cognitive behavioral therapy for 2 months (three sessions per week). The therapy sessions included imagination strategy, relaxation sessions, refute of irrational ideas, uprooting distorted ideas and beliefs, adopting positive ideas, and assertive and positive self-talk. Change took place with the help of expressive pictures and photos of modeling to influence the girl and her beliefs. Her religious tendency and the positive relation she had with the therapist were useful in rebuilding her cognitive setup. The sessions also included guiding the mother on how to contain and deal with her daughter.

   Discussion Top

The present case illustrates that a person with gender dysphoria may benefit from psychological intervention to explore his/her desire for sex change. Current understanding and advanced biogenetic research suggest that both biological and classical psychoanalytical predisposition may act as etiological factors for gender dysphoria. This biological factors may be considered as general vulnerability to psychopathology and psychosocial factors that shape that presdisposition. [6] Little is known about the long-term prognosis in people who underwent sex change operation from the Arab world, but a few studies suggest that the majority end up living as homosexuals. [7] Others regret such procedures and wish they were fully informed about the long-term consequences and challenges before the surgery. Gender identity disorder or transsexualism has been described in patients with 47, XYY Karyotype [8] Klinefelter's syndrome and psychotic disorders. [9] Cases have been described where the patient's gender dysphoria improved after tearing the symptoms of schizophrenia with antipsychotic medication. [10] International guidelines in the management of people with gender dysphoria recommend a multidisciplinary team approach with psychotherapy and counseling as essential part of their treatment. These treatments should consider the preferences, needs, and circumstances of the particular patient. [11] Although the literature on the role of psychotherapy for gender dysphoria is limited and the evidence for its efficacy is controversial, it has always been incorporated into any comprehensive multifaceted approach for the management and assessment even after the sex reassignment surgery. [12] Studies from the West reported psychotherapy to be relatively helpful for some patients with gender dysphoria and to have favorable outcomes with one third of the patients would be good candidates for it. [12] It is worth noting that the aim of psychotherapy is not to treat gender dysphoria by "curing" the patients' "misperceptions" about their gender. But by guiding them to feel comfortable in their gender identity, allowing them to have fair opportunities to be able to form successful relationships, pursue their education and occupation, and fulfill the rules in the society. [13] This is can be achieved by enabling insight, working out coping strategies, giving psychological support, and providing the patient with information about their treatment options. Some psychotherapeutic interventions include allowing the patients to explore their gender identity and sexuality in a nonjudgmental manner, providing supportive atmosphere, as well as facilitating a "coming-out" process. Keeping the "secret" of one's transgender identity from others might lead to an emotional distress, [14] but, on the other hand, disclosing it to all may result in bullying.

Psychotherapy is generally conducted on a one-to-one basis, but some patients may benefit from couple, family, group, and relationship therapies. Involving parents can be helpful because the failure of parents to understand the authenticity of the patient's identity is viewed as a barrier to the patient achieving a sense of self-acceptance. [15] Group therapy and general support groups offer the opportunity to foster peer support.


We thank the patient and her family for giving us consent to publish this case.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 th ed. Washington, DC: American psychiatric association ; 2013. p. 451.  Back to cited text no. 1
Tamis-LeMonda CS, Balter L. Children′s Dynamic Gender Identities Across Development and the Influence of Cognition, Context, and Culture. 2015.   Back to cited text no. 2
Lawrence AA. Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults. Arch Sex Beh 2010;39:514-45.  Back to cited text no. 3
Okabe N, Sato T, Matsumoto Y, Ido Y, Terada S, Kuroda S. Clinical characteristics of patients with gender identity disorder at a Japanese gender identity disorder clinic. Psychiatry Res 2008;157:315-8.  Back to cited text no. 4
Bakker A, van Kesteren PJ, Gooren LJ, Bezemer PD. The prevalence of transsexualism in The Netherlands. Acta Psychiatr Scand 1993;87:237-8.  Back to cited text no. 5
Bradley SJ, Zucker KJ. Gender Identity Disorders. International Encyclopedia of the Social and Behavioral Sciences. Orlando, FL, USA: Elsevier; 2001. p. 6011-16.  Back to cited text no. 6
Baudouin D. Sexual morality at the Egyptian bar: Female circumcision, sex change operations, and motives for suing. ILS 2002;9:42-69.  Back to cited text no. 7
Haberman M, Hollingsworth F, Falek A, Michael RP. Gender identity confusion, schizophrenia and a 47 XYY karyotype: A case report. Psychoneuroendocrinology 1975;1:207-9.  Back to cited text no. 8
Singh D, Deogracias JJ, Johnson LL, Bradley SJ, Kibblewhite SJ, Owen-Anderson A, et al. The gender identity/gender dysphoria questionnaire for adolescents and adults: Further validity evidence. J Sex Res 2010;47:49-58.  Back to cited text no. 9
Baltieri DA, De Andrade AG. Schizophrenia modifying the expression of gender identity disorder. J Sex Med 2009;6:1185-8.  Back to cited text no. 10
Cassels C. New treatment guidelines for gender dysphoria released. Medscape Medical News. Available from: [Last accessed on 2013 Oct 28].  Back to cited text no. 11
Seikowski K. Psychotherapy and transsexualism. Andrologia 2007;39:248-52.  Back to cited text no. 12
Coleman E, Bockting W. Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism 2012;13(4):165-232.  Back to cited text no. 13
Cole CM, O′Boyle M, Emory LE, Meyer WJ 3 rd . Comorbidity of gender dysphoria and other major psychiatric diagnoses. Arc Sex Behav 1997;26:13-26.  Back to cited text no. 14
Larry N, Rosenblum A, Blumenstein R. Transgender identity affirmation and mental health. International Journal of Transgenderism 2002;6.4:97-103.  Back to cited text no. 15


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